January 2, 2009
Employee name
1900 N Third Street
Clinton, IA 52733
Dear Eric,
According to our records, your recent absences may be covered under the Family and
Medical Leave Act.
On January 15, you provided medical certification to the Human Resources Department.
This certification is insufficient because it does not include the 1) notation of the serious
health condition 2) medical facts to support your request 3) date the condition
commenced 4) the probable duration 5) statement that the eligible employee is unable to
perform the functions of the employee’s position 6) employee signature.
You must provide sufficient medical certification to the Human Resources Department
within 15 calendar days from the date of this letter. Enclosed is a form that must be
completed by your health care provider. Failure to provide this certification will result in
denial of FMLA leave and this absence will be counted in accordance with our
attendance policy.
If you have any questions or concerns, please contact me immediately.
Sincerely yours,
Employee name
Company